Blood cancers

Renal impairment not an excuse to deny ASCT in myeloma

Myeloma patients with even severe renal impairment should still have the opportunity to receive autologous stem cell transplants, according to data from the Australian and New Zealand Myeloma and Related Diseases Registry.

A study of 843 patients, presented at the HAA 2017 Annual Scientific Meeting in Sydney, found no difference in clinical response rates to therapy on the basis of renal function.

About 60% of transplant eligible patients, assessed by age 70 or below, with any degree of renal impairment underwent a transplant compared to 73% of patients with normal renal function.

Almost two thirds of patients (65%) with eGFR 30-59 ml/min, 40% of patients 15-29 ml/min, and 65% of patients with severe impairment (eGFR <15 ml/min) received transplants.

Haematologist Professor Joy Ho, from the Royal Prince Alfred Hospital, said even patients with renal impairment less 30 ml/min had better overall survival following transplant than those who did not have a transplant.

“We get this question all the time. If a patient already has renal impairment, should they have a stem cell transplant? So we have Australasian data now.”

“These findings support the benefit of transplant in myeloma patients with renal impairment at all levels of renal function.”

However the lower rate of transplantation in patients with renal impairment compared with those with normal renal function showed there were remaining concerns about the potential toxicity of associated drugs such as melphalan.

The study found about 36% of myeloma patients already have some degree of renal impairment at diagnosis – 23% with eGFR 30-59 ml/min, 6% at 15-29 ml/min, and 7% less than 15 ml/min.

“So the damage is done early but it is reversible. It’s well known that if you start therapy promptly, particularly proteasome inhibitor therapy, that renal failure can be reversed.”

The study found 83% of registry patients who had renal impairment received a proteasome inhibitor and reassuringly, that the median time from diagnosis to treatment was shorter in patients with renal impairment than those with normal renal function (14 v 24 days).

Professor Ho said it was perhaps not surprising that patients with renal impairment were typically older and had higher stage disease.

“The study showed that patients with renal impairment have higher LDH and/ or more high risk cytogenetic changes as detected by FISH. These include deletion 17p, translocation 4;14, translocation 4;16 and amplification 1q21.”

“We found that 55% patients with renal impairment were in the high-risk group based on LDH or cytogenetic changes compared with 45% of those with normal renal function.”

“And that may have implications for utilising more powerful therapy, for example, more than one novel agent. We have great treatments, but even though we know what is high risk in terms of cytogenetics, there is no clearly defined risk adapted therapy yet.”

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